Wednesday, January 25, 2023

Micrographia In Parkinson’s Disease

Motor Automaticity Related Clinical Presentations In Pd

PDMDS Workshop on Micrographia in Parkinson’s-Improving your Handwriting

Deterioration of motor automaticity is a general feature in PD patients. In fact, most bradykinesia related clinical presentations can be associated with this problem, as PD patients tend to perform almost all daily behaviors slower or with smaller amplitude. Even in the early stage of PD, the ability to perform automatic behaviors, like arm swing, gait, eye blinking, facial expressions, speech modulation and swallowing, is already impaired. Using external cues or directing attention to these behaviors is always beneficial. One effect of external cues is to draw attention to the movement, thus use more attentionally controlled behavior instead of an automatic pattern. Attentional control is flexible but slow and carries comparatively high computational costs as opposed to the fast but inflexible automatic mode . In healthy people, while attention is always helpful to improve motor performance at early-learning stage, it can disrupt the performance of well-practiced skills . Thus, healthy people tend to use automatic control instead of attentional control to perform daily behaviors. In contrast, as the ability to perform automatic movements is impaired, these motor skills actually revert to the early-learning stage, PD patients have to rely on attentional control helping to perform motor skills that usually executed automatically in healthy people.

Micrographia As A Sign Of Parkinson’s Disease

Handwriting that’s getting progressively smallersomething doctors call “micrographia”probably doesn’t seem like a major problem. But if your handwriting is smaller than it used to be and getting smaller still, it could be a symptom of a medical condition such as Parkinson’s disease.

Parkinson’s disease is a brain disease that causes loss of balance, stiffness, slow movement, and sometimes a tremor. It’s progressive, which means it will tend to get worse over time, and it can’t be cured. However, there are treatments available that can help to keep your symptoms under control.

Micrographia is one of those symptoms, and in fact, it can be an early warning sign of Parkinson’s. People with Parkinson’s disease tend to find their handwriting gets smaller, even though they don’t intend to write smaller.

In Parkinson’s, the words you write may be closer together on the page , and your letter sizes may be smaller, too. Finally, your writing may tilt upward to the right on the page. All these are signs of micrographia.

What Strategies Can Help You Manage Micrographia

Handwriting Training

The first strategy is regular practice. Just as practicing your penmanship in elementary school helped you improve your handwriting, taking time each day to work on your writing now can improve your physical ability to write.

Whats more, regular training may even alter your neural pathways. A 2018 study that investigated cortical network changes in 42 people with Parkinsons found that six weeks of intensive writing training modulated neural connectivity between task-related cortical regions in people with Parkinsons. The study participants who received prolonged and intensive writing training displayed significant connectivity changes within the handwriting network. The connectivity targeting the brains supplementary motor area , a part of the cerebral cortex that helps control movement, increased through the influence of an enhanced left-hemispheric visuo-parietal coupling. Because the SMA is a major output region of the basal ganglia, poor functioning of the SMA and basal ganglia can impact voluntary, automatic movements like handwriting. Strengthening the coupling between two areas, therefore, may result not only in better handwriting but also in improved motor learning.

Occupational Therapy
Assistive Tools and Devices
Adjustments to Writing Style

Writing in print rather than cursive can help improve micrographia because it forces you to slow down and make a deliberate effort to form each letter. This can make your writing more legible.

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Standardized Handwriting To Assess Bradykinesia Micrographia And Tremor In Parkinson’s Disease

  • Affiliation Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

  • Affiliation VTT Technical Research Centre of Finland, Tampere, Finland

  • Affiliation VTT Technical Research Centre of Finland, Tampere, Finland

  • Affiliation VTT Technical Research Centre of Finland, Tampere, Finland

  • Affiliation The Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom

  • Affiliation Manus Neurodynamica Ltd, Newcastle, United Kingdom

  • Affiliation Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

  • Affiliation Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

Why Does Parkinsons Disease Cause Micrographia

A case of stroke induced micrographia

PD damages many areas of the brain. Scientists believe that PDs effects on the basal ganglia and the cortex of the brain cause bradykinesia, which can lead to micrographia. The basal ganglia are a group of neurons located deep in the brain that process information on movement and play an important role in planning actions to achieve specific goals, such as using hands to catch a ball or write with a pen. The basal ganglia work in cooperation with the cortex to signal and activate muscles. As PD progresses, the impulses from the basal ganglia are insufficient to prepare and execute the commands to move. Several additional factors that contribute to bradykinesia in people with PD include muscle weakness, rigidity, tremor, movement variability , and slowing of thought.3,4

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Slowness Of Simple Repetitive Movements

When PD patients attempt to perform a simple repetitive movement, the movement is typically executed slowly and accompanied by a higher timing variability. Clinically, some simple repetitive movements, e.g., finger tapping, opening and closing the hand, or tapping the foot on the ground, are commonly used to assess the bradykinesia. The neurophysiological mechanisms underlying this phenomenon have been investigated for a long time. Inadequate force of the initial impulsive activity in the agonist , and inappropriate scaling of the dynamic muscle force to the movement parameters are some likely reasons. It has been suggested that the impaired basal ganglia-thalamo-cortical pathway results in decreased basal ganglia outputs, which in turn produces slowed movements . An alternative explanation is that the slowness of movement in PD is due to inadequately activated motor cortical and spinal cord centers because of dopamine reduction not only in basal ganglia, but also in cortical and spinal sites .

Why Attention Improves Micrographia

Attention significantly improved both consistent micrographia and progressive micrographia , which is consistent with previous reports that external cues or attention could improve handwriting in Parkinsons disease . In both controls and patients, attention to writing commonly enhanced activity in the DLPFC compared to the free writing condition . The DLPFC is critical in attentional networks . Greater activation of the DLPFC when attending to learned movements has been reported .

Attention increased activation in the caudal SMA or pre-SMA in healthy subjects, but not in patients with Parkinsons disease. This may be a consequence of the dysfunction of basal ganglia motor circuit. In healthy controls, the enhanced activity and connectivity was restricted to the cortical areas and cerebellum. In contrast, attention was accompanied by increased activity in the left anterior putamen in both consistent micrographia and progressive micrographia patients . In addition, patients with consistent micrographia had increased connectivity between the anterior putamen and PMC/caudal SMA, whereas patients with progressive micrographia had strengthened connectivity between the anterior putamen and pre-SMA/rCMA . Moreover, these connections were positively correlated with the improvement of micrographia. These findings demonstrate that attentional strategies recruit the anterior putamen-cortical motor circuit to improve handwriting in patients with Parkinsons disease.

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Who Is Saba Shahid Ms

She is the Chief Smiling Officer of Creative Neurology. She is also the author and creator of the Lets Combat Micrographia® Books and Workshop series.

Saba was instrumental in developing Lets Combat Micrographia® in 2014 after seeing a need to educate the public, professionals, and most importantly provide a resource to those living with Parkinsons disease. Creative Neurology®, formerly known as The Art Cart, is the only organization in the world that provides research-based programming to those living with micrographia. The Lets Combat Micrographia® resources and workshop series her group has developed is listed by the National Library of Medicine.

Can Micrographia Be Reversed

Micrographia Exercises & Tips for People with Parkinson’s| Parkinson’s Society India

There are ways to improve the small, slanted, illegible handwriting and make it larger and more legible. Improving handwriting requires discipline and focus much like the same type of discipline needed when starting a new exercise routine.

Lets imagine getting back into an exercise routine. The first time you go to the gym and get on that treadmill you feel the burn instantly. As each week goes by, your cardiovascular endurance builds, you feel stronger and are able to push yourself more. The week you decide to stop exercising to take a few weeks off, you will notice a decline in your endurance. Improving micrographia is similar to this experience. The more you practice, the more you write, the easier it will be. However, if you stop writing you will notice your handwriting may start to get smaller again.

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Striatal Dopaminergic Regulation Of Micrographia In Parkinsonism

M. Eklund, J. Joutsa, S. Nuuttila, E. Mäkinen, E. Jaakkola, T. Noponen, T. Ihalainen, M. Koivisto, S. Teperi, F. Scheperjans, V. Kaasinen

Session Time: 1:45pm-3:15pm

Location: Agora 3 West, Level 3

Objective: To investigate the role of brain dopamine function in writing and drawing micrographia of patients with parkinsonism.

Background: Micrographia, an abnormally small or progressively decreasing handwriting or drawing, is a common symptom in parkinsonism, but it may also occur in other neurodegenerative diseases . The pathological mechanism of micrographia is poorly understood although it is likely to be related with dysfunctional basal ganglia motor circuits . Levodopa improves micrographia, which suggests that dopaminergic modulation could be important. However, brain in vivo dopamine function has not previously been studied in relation to micrographia.

Method: Altogether 322 patients with tremor or parkinsonism underwent brain dopamine transporter FP-CIT SPECT imaging for diagnostic purposes. Immediately before scanning, the patients provided writing and drawing samples. Detailed clinical examinations including MDS-UPDRS part III were performed. Striatal DAT binding was analyzed using semi-automated region of interest method. Associations between different types of micrographia and DAT binding were analyzed using linear regression models with and without covariates.

To cite this abstract in AMA style:

Mov Disord.

Neural Mechanisms Underlying Deficits Of Automaticity In Pd

Only few imaging studies have investigated motor automaticity in PD . These studies found that even at a relatively early stage, motor automaticity is already impaired in most PD patients. The patients need greater activity in several regions, i.e., the DLPFC, PMC, parietal cortex, and cerebellum, compared with normal subjects while performing automatic movements . The hyperactivation in these regions have been extensively reported in PD while performing various motor tasks, and is possibly a compensation for the dysfunction of basal ganglia . Additionally, there was less effective connectivity between motor areas that are associated with the production of automatic movements in PD patients . The more activation outside M1 and less connectivity between motor areas indicate a less efficient neural coding of movement in PD patients compared to healthy people.

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Improving Micrographia By Closing Eyes While Writing

One study found that micrographia was improved in people with PD when they closed their eyes while writing. Closing the eyes took away the visual feedback that is normally present, and this simple activity seemed to improve micrographia, particularly among people with PD who were not taking medication for PD. Following the clinical trial, the study authors noted that many of the study participants continued to use this method of closing their eyes while writing, especially when writing their signature.6

What Is Motor Automaticity

Micrographia and related deficits in Parkinson

Automaticity is the ability to perform movements without attention directed toward the details of the movement, particularly for movements that require low levels of precision or for movements that are commonly made . After a period of training, and passing through several distinct phases, including fast , slow , and consolidation stages , even some complex motor skills can be well established and achieve the automatic phase . At this stage, motor skills can be performed requiring minimal cognitive resources and are resistant to interference and the effects of time. In fact, most of our daily behaviors are carried out automatically. From getting up in the morning, brushing teeth, eating breakfast with spoon, fork or chopstick, to walking or driving to work, people usually pay little attention to these motor behaviors. For example, people can talk on cell phone while walking even when focusing on talking, they still can maintain walking smoothly without difficulty.

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What Are The Benefits Of Handwriting

· Stimulates the Brain: Handwriting is a rich mind-body experience that helps stimulate the brain. When writing you are working on creating letters, joining those letters to other letters, then creating words, and ultimately forming sentences. This requires brain power.

· Develops Fine Motor Skills: Handwriting exercises a complex cognitive process involving neuro-sensory experiences and fine motor skills. The ability to hold a tiny pen or pencil requires strength and coordination. Continuing to write as well as to perform hand stretches may help develop fine motor skills.

· Increases Focus: Writing increases focus because we are forced to slow down, think about forming letters into words, and then into sentences. Our brain is working extra hard to string all the pieces together.

· Helps Improve Memory: Handwriting may in some cases improve a persons memory for new information as the act of writing requires more focus and allows you to visualize what is in front of you. In our Lets Combat Micrographia® Workshops, we often take a walk down memory lane and write about our favorite past experiences.

There are also more papers and research on micrographia in Parkinsons disease and we recommend the following articles:

Functional Magnetic Resonance Imaging

Functional MRIs were performed on a 3 T MR scanner . A standard head coil was used with foam padding to restrict head motion. High-resolution axial T 1 – and T 2 -weighted images were obtained in every participant to detect clinically silent lesions. High-resolution anatomical images were acquired with 3D-MPRAGE sequence . Blood oxygen level-dependent data were acquired with gradient-echo echo-planar sequences .

During functional MRI scanning, subjects had a locally developed MRI-compatible graphic tablet placed on a cushion over their laps, and held a fibre optic pen in the right hand. The tablet could be oriented in the MRI scanner so that the writing posture could be comfortably adjusted. The subjects could see the tablet and what they have written on the tablet clearly through a mirror built into the head coil. Each functional MRI scan session lasted 8 min, was block designed and contained two conditions, which were defined as the rest and write condition, respectively. Each condition lasted 40 s and was repeated six times. In the rest condition, the subjects were asked to relax and focus on the tablet. During the write condition, the subjects performed following writing tasks as required.

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What Needs To Be Further Investigated

Several important issues on motor automaticity in PD remain unclear and need further investigation. First, the neural mechanisms underlying defected motor automaticity is not fully understood. Previous studies have focused on the striatum, cortical motor networks and attentional networks the role of other regions associated with motor learning should be investigated in future. Second, the degree impaired motor automaticity contributes to bradykinesia is unclear. Third, whether L-dopa or surgical treatments improve motor automaticity has not been fully investigated. Fourth, whether motor automaticity has the potential to be used for early diagnosis and a target for treatment of PD also needs further investigation.

Strengths And Limitations Of This Study

Micrographia and Dextrous Movement Problems in Parkinsonism
  • Large sample size, systematic assessment methods.

  • This study is a cross-sectional single-visit study, does not determine the effects of dopaminergic medications or shed light on the therapeutic measures.

  • The study finds significant correlation of cognition with micrographia based on MMSE testing but does not use detailed cognitive assessment battery.

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Assessment Of Hypophonia And Bradykinesia

Thirty-eight PD subjects reported presence of hypophonia when specifically asked on history. Thirty-six subjects showed a decline of 10dB when decibel meter scores were used for determination. Cohen’s revealed significant correlation between hypophonia assessment on history and objective assessment . On 2 testing, there was significant difference between decibel meter scores in PD cohort and controls . There were 54 subjects who reported bradykinesia when specifically asked on history. Their quantitative assessment results are shown in .

Functional Mri Acquisition And Preprocessing

Imaging was carried out in a Philips Achieva 3T scanner . A standard head coil was used with foam padding to restrict head motion. High-resolution T1-weighted anatomical scans and T2-weighted functional images were acquired for each participant using gradient echo-planar imaging pulse sequence .

Functional imaging data were pre-processed using SPM8 implemented in Matlab . All functional images were realigned to the reference image and co-registered to each subject’s T1 anatomical image. All images were normalized to Montreal Neurological Institute space using the segmented anatomical image and smoothed with a 6-mm full width at half maximum Gaussian kernel. Differences in head motion parameters between groups were tested using the framewise displacement method . There was no difference between the experimental and placebo group at baseline and post-training or between baseline and post-training in the experimental and placebo group .

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Other Symptoms Of Parkinsons Disease

The primary motor symptoms of PD are tremor, rigidity, postural instability , and bradykinesia. PD also causes many secondary motor symptoms, including changes in gait , changes in speech, stooped posture, dystonia , cramping, difficulty swallowing, sexual dysfunction, impaired fine motor dexterity, and akathisia . In addition to these motor symptoms, PD can cause non-motor symptoms such as depression, difficulty swallowing or chewing, urinary problems, constipation, skin problems, sleep problems, pain, and cognitive problems, such as memory problems or slow thinking.1,7

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